Death of a infant 13 hours after delivery was the result of the mother and child being let down by the hospital and three women involved in maternity care, Health and Disability Commissioner Anthony Hill has ruled.

The mother, Ms A, 21, lost her first child after three days in an unnamed hospital administered by the Northland District Health Board (NDHB) in 2009.

Not only did the DHB fail in its duty of care, but so did the lead maternity carer, Ms B, hospital midwife Ms C and clinical midwife manager Ms D.

"In this case, the care of Ms A and her baby was dependent on the seamless transfer of her care, and effective communication between (Ms B) and the DHB staff, and between staff within the DHB.

"A system designed to ensure that patients receive timely, appropriate, specialised care failed to deliver."

Mr Hill said he was not convinced the DHB had taken "sufficient steps" to provide appropriate services to the mother.

The fate of the baby depended on the cardiotocogram (CTG) for measuring foetal heart rate but Mr Hill found that midwife Ms C had limited current midwifery experience and had only just returned to work after a two and a half year break.

He found that Ms B's care of the mother had been adequate on the first three days but after 4.30am on day three she failed to provide services with reasonable care and skill by failing to carry out adequate monitoring of foetal and maternal well-being.

On day three Ms C "failed to exercise reasonable care and skill when she resumed care" by failing to correctly interpret the abnormalities in the foetal heart rate on the CTG trace, and the uterine liquor colour, which were signs of foetal compromise.

Ms C had told the commissioner that she had felt reassured by the CTG because Ms D had glanced at it and that she was "embarrassed to ask for more help".

Rather than measuring the baby's heart rate, the evidence showed she was monitoring the mother's.

Later on day three Ms C called for assistance and the clinical midwife manager Ms D attended.

The commissioner said Ms D knew that Ms C was a new employee and once that Ms D became aware the CTG was recording the maternal, rather than the fetal heart rate, "she should have taken the initiative and reviewed the entire CTG trace."

The baby was born at 10.08 am on day three after a "significant delay".

The commissioner said Ms D failed to provide Ms C with adequate support and supervision.

Ms B and Ms D had been ordered to apologize for breaches of the Midwives Code of Ethics.

Ms C has already provided her letter of apology and she had told the commissioner she would not return to practice.